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H.RAMLAN SADELI,dr.MS,SpMK
CLINICAL MYCOLOGY
Introduction to Mycology :
1. History, and development of mycology
2. Structure, morphology, classification and taxonomy of fungi
3. Growth and cultivation of fungi
4. Diagnostic and examination of fungal disease
Introduction to Mycology
In modern mycology, the fungi are placed within a separate Kingdom :
1. Monera
2. Protista
3. Fungi
4. Plantae
5. Animalia
Phyllum Eumycota, the four classes of fungi in which the human pathogens are
placed :
Fungi (Kingdom)
Eumycota (Phylum)
Classes : Zygomycetes
Ascomycetes - yeast
Basidiomycetes - mushrooms
Deuteromycetes - asexual (anamorph)
state only
Classes :
1. Zygomycetes :
is characterized by the production of large, non-septate (coenocytic) hyphae
and sporangia
are found everywhere, they produce diseases most often in diabetics
2. Ascomycetes :
are identified by their sexual (teleomorphic) state
since this state is not often seen in the laboratory, the fungi found as human
pathogens usually are not identified in this class
telemorph state is characterized by production of ascus (or sac) within which
sexual spore are produced (ascospores)
Classes :
3. Basidiomycetes :
are identified by their sexual (teleomorphic) state
the teleomorphic structure is the basidium and sexual spores, basidiospores,
are produced on the outside of the basidium
1. Yeast :
may bud from another mature cell
or from the septal area of certain hyphal fungi
2. Hyphae :
is the thread-like structure that form the cell body of most fungi
may be large ang without cross-walls (septae) :
non-septate or coenocytic; is found in the Zygomycetes
may be thinner and produced cross-walls (septae) :
septate hyphae; are formed by all other fungi
Structures :
4. Sporangiospores :
asexual cells developed within a sporangium
produced by the Zygomycetes
1. Skin scrapings :
clean the lesion of dirt or any topical medicines
scrape the outer edge of the lesion with a scalple
collect the scrapings in a clean container
2. Hair : remove hair from the infected site with clean forceps
collect in a clean container
3. Biopsied tissue :
placed in a sterile containers;
add steril water or saline to keep the tissue moist
do not freeze the tissue
4. Exudate or pus :
should be aspirated from an unopened abscess
placed in a steril tube and taken directly to the laboratory
never let the specimen dry
Collection of specimens :
5. Sputum :
before collecting the sputum, the patient should brush his teeth or remove his
ask the patient to take a deep cough and raise sputum from the lung
7. Spinal fluid :
collect aseptically and place into a sterile tube
often provide a rapid, tentative diagnosis (without having to wait for the
culture to grow)
most mycological specimens are examined in the fluid state (wet mount),
include a KOH (or NaOH) preparation, India ink. lactophenol-cotton blue
Processing of specimens :
Culture media for isolation and identification :
The proper selection of isolation media is critical to obtaining a laboratory
diagnosis of a fungal disease. If the wrong medium is used, the fungus causing
disease may not grow.
can act as a selective factor (incubation at 45C will inhibit most fungi and
bacteria, but not Aspergillus fumigatus)
Processing of specimes :
Primary isolation media :
non-selective : Sabouraud dextrose agar
Brain heart infusion agar
Blood agar base
Disease Agent
the term versicolor is particularly appropriate, since color of the lesion varies
according to the normal skin pigmentation, exposure to sunlight & severity of
infection
lesion occur more often on the upper body, face, neck, arm
the reason for a change from normal flora status to a pathogenic agent are not
clear
PITYRIASIS VERSICOLOR
Laboratory diagnosis :
wet mount of skin scales : lesion contain short typical elements & spherical
cells (yeast) & this observation is virtually pathognomonic (spaghetti & meat
ball appearance)
Treatment : keratolytic agent such as salicylic acid or sulfur have been used;
topical miconazol
SUPERFICIAL MYCOSIS
BLACK PIEDRA
infection of hair shaft (of the scalp), characterized by black, hard nodules on
the hair shaft; very difficult to remove the nodules
in some area of the world, the infection may be encouraged for cosmetic
purpose
diagnosed by direct examination of the hair & nodules; reveals hyphal strands
are often aligt along the periphery of the mature nodules; and the center of the
mass resembles organized tissue with area in which asci are produced
WHITE PIEDRA
direct examination of the hair sharf reveal the mass of intertwined hyphae of
the nodules; often fragmented into arthroconidia
Dermatophytosis :
may involve the skin, hair, nails (parts of the body which contain keratin)
may be acquired from animal (zoophilic), soil (geophilic), in which lesion are
quite inflammatory & may heal spontaneously
may be acquired from human (anthropophilic); usually less inflamation but
may be chronic
dermatophytosis are classified by the area of the body involved
DERMATOPHYTES
Clinical features :
graypathes ringworm/epidemic tinea capitis
blackdot ringworm
kerion / zoophilic (geophilic) tinea capitis
TINEA CAPITIS
Grapatches ringworm :
Blackdot ringworm :
caused by T.tonsurans; occurs in adults & is a chronic infection
characterized by hair breakage, leaving follicles with dark conidia (the hair
shaft breakage right on the surface of the scalp);
may be results in alopecia; usually treated with griseofulvin or ketoconazol
Kerion :
occurs primarily in children; usually transmitted by pets; accordingly by farm
animals
is most commonly caused by M.canis or T.mentagrophytes; more
inflammatory & occurs with kerion
may results in inflammation, keloid, kerion, & alopecia
my heal spontaneously; but usually treated with antifungal
DERMATOPHYTOSIS
TINEA BARBAE :
is an acute or chronic folliculitis of the beard, neck or face
is most commonly cause by zoophilic dematophytes (T.verrucosum;
T.mentagrophytes)
results in pustular; or dry, scally lesion; my be superinfected with bacteria;
treated with griseofulvin
DERMATOPHYTOSIS
TINEA CORPORIS :
is fungal infection of the glabrous skin; most commonly caused by T.rubrum,
T.mentagrophytes & M.canis
is characterized by annular lesion with active border & may be vesicular or
pustular
is treated with topical antifungal (tolnaftate, myconazol) or griseofulvin
(systemic)
TINEA IMBRICATA
is caused by T.concentricum; occurs on Pacific Ocean Islands & numerous
countries of Asia
is characterized by concentric ring on the skin; may cover large area of the
body; the scally often overlap
is treated by griseofulvin
DERMATOPHYTOSIS
TINEA PEDIS
TINEA PEDIS
Clinical features : vesicular tinea pedis
is characterized by vesicles & vesiculopustules
permanganate or Burrows solution is used to open vesicle;
dermatophytid reactions my occur;
griseofulvin is the treatment of choice
TINEA MANUM :
is chronic, unilateral fungal infection of the hand, caused by T.rubrum,
T.mentagrophytes, E.floccosum
is characterized by diffuse hyperkeratotic; exfoliative, vesicular;
treatment = tinea pedis
DERMATOPHYTOSIS
TINEA UNGUIUM :
debris + non
pain non +
thickness + non
DERMATOPHYTOSIS
Laboratory diagnosis :
Laboartory diagnosis :
species identification requires culture
culture identification is based primarily on the appearance of the asexual
reproductive conidia or the specific hyphae
while all of these species grow as molds, they have distinctive features
the reverse of colonies of some species may be pigmented (red, yellow) and
the tops may be fluffy, velvety; white or pigmented
this characteristics combine with the microscopic morphology generally
permit an identification
SUBCUTANEUS MYCOSES
Diseases Agent
Mycetoma pedis
Eumycetoma Pseudoallescheria boydii; Madurella sp;
Acremonium sp; Fusarium sp;
Actinomycetoma Actinomyces israeli; Nocardia sp; Streptomyces
sp; Acinomadura sp;
General characteristic :
Eumycetoma : Actinomycetoma :
Laboratory diagnosis :
direct microscopic examination : granules obtain from the draining tissues are
examined for ther gross physical characteristic
microscopic examination (wet mount with KOH) reveal that bacterial filament
less than 1 um; & fungi filamen (hyphae) greater than 1 um
Treatment :
CHROMOBLASTOMYCOSIS :
SPOROTRICHOSIS
caused by Sporothrix schenckii, a dimorphic fungus, is found worldwide as
inhibitant in soil & decaying vegetation
is characterized by a lesion that begin as a movable nodule & subsequently
became necrotic
if it is untreated, new lesion appear along the lymphatic draining area (this
pattern is pathocnomonic for this form of sporotrichosing)
the infections is particularly associated with gardener --> rose gardener
syndrome
SPOROTRICHOSIS
in endemic area, a non-lymphatic or fixed form may be seen
single lesion, do not spead, often found on the face, neck or finger (occurs in
hypersensitive / allergic person)
another form of non-cutaneus, systemic infections is pulmonary infections; is
seldom diagnosed & often found in chronic alcoholic; infections is initiated
following inhalation of fungal conidia
SPOROTRICHOSIS
Laboartory diagnosis :
however, the number of orgnaism is often too few for releable observation and
material should be submitted for fungal culture
SPOROTRICHOSIS
Laboratory diagnosis :
the organism is thermally dimorphic; in soil or at room temperature is grows
as mold with distinctive conidia that are produced in a pattern often described
as a daisy head
Treatment :
KI (pottasium iodida), oral; topical
amphotericin B
SUBCUTANEUS MYCOSES
RHINOSPORIDIOSIS
in tissue, the organism a large (6-300 um), spherical sporangia (sperula) that,
when mature, is filled with endospres; on lysis, these endospore then repeat
the development sequence
Diseasea Agent
or decaying wood associated with soil, has been isolated several times, but
repeated isolation from the same sites were not succesful
most of the cases have been found in Noth America, but also prevalent in
Africa & has been reported in India, occurs most often in adult males
the lack of a specific skin test antigen has prevented the determination of the
prevalence of asymptomatic Blastomycosis in large population
BLASTOMYCOSIS
Cxlinical features :
the primary site of Blastomycisis is the lung, with mild infiltrat & few clinical
symptoms
in severe disease, pulmonary infiltrate may be more extensive & the patients
will have fever, cough & weight lose, nodular pulmonary lesion may occur
some cases may progres to chronic disease with pulmonary fibrosis & the
cavitation
the fungus may disseminate to any organ of the body, mostly skin & bone
skin lesion are frequently a manifestationof disseminated disease, with
dry & scaly, extensive granulomatous with vescle or pustule
BLASTOMYCOSISIS
Laboratory diagnosis :
Direct microscopic examination :
histiphatology : the yeast form is usually easily fount in infected tissue, are
best detected with PAS or GMS stain
BLASTOMYCISIS
Laboratory diagnosis :
Culture :
is the dimorphic fungus, that grws in the mycelial form (mold) at room
temperature & as a yeast at 370C
the mold form grows slowly, became visible in 7 - 10 days, the colony is
usually white & cottony
the yeast-like colony grows on blood agar at 370C after 3 - 4 days
Microscopic morpology :
the mold produces small, smooth walled cinidia & attached to the
conidiophores that arise directly from the hyphae
yaest are large, thick-walled, single-budding & the bud has a wide base (neck)
the diagnostic structure of B. dermatitidis
BLASTOMYCOSIS
Serology :
ID test is the most reliable, CFT not detect antibodies in all cases, will
cross-react with antibodies to H. capsulatum
often be isolated from old building/caves, where birds/chickens or bats have roosted
H. capsulatum grows in soil in the mycelial form & large number of conidia are
produce
the disease is acquired by inhaling conidia & reported from most area of the world
HISTOPLASMOSIS
Clinical features :
is primarily a pulmonary disease; when conidia are inhaled, infections is established in
the lungs; the disease may be mild, with few or no symptom (95%)
the most severe form of histoplasmosis is disseminated disease; the fungus invade any
organs of body
HISTOPLASMOSIS
Laboratory diagnosis :
Direct microskopic examination : wet mount :
histopathology : the yeast form can be found in tissue removed from the
infected sites, ussually in the macrophage & in granulomas
Culture :
colony morphology : H. capsulatum grows slowly in the mold form when incubated at
room temperature, appear in 7 - 10 days but conidia is not form until later; on SDA
( sabouraud dextrose agar ) the colony Is ussually white & cottony
microscopic morphology :
two types of conidia are prodeced by H. capsulatum small, pyriform smoth-walled
conidia (microconidia, 4 - 6m ) and large, round, thick-waled tuberculated conidia
( macroconidia, 8 - 18m ) the diagnostic conidia
to prove the identification of H. capsulatum, convert the mold form - yeast form; be
done by transferring the mold colony to blood agar & incubate at 37 0C in 3 - 5 days the
yeast colony will be white brown
HISTOPLASMOSIS
Serology :
antibodies to the fungus are produced within 10 - 21 days after a person is infected by
H. capsulatum
CFT, measures both IgM & IgG, is quantitative test; ID test is a quantitative test
Treatment :
Amphotericin B, Ketoconazole
COCCIDIOIDOMYCOSIS
= valley fever
Epidemiology :
C. immitis grows in semi-acrid, solid, is known to exist in North, Central,
& South American, especially California; its inhaled into the alveoli, where it
produces disease, either benign ( resembles flu ), or acute, depending on many
factors ( race; incculum )
Clinical features :
most is a benign disease, prodeces only mild symptoms; among certain races
( Filipinos, Black ), immunosupressed or the used of corticosteroids,
disseminated may occur
there is no site of predilection for this organism; any body tissue may become
infected
COCCIDIOIDOMYCOSIS
Laboratory diagnosis :
Direct microscopic examination :
Serology : used as diagnostic & prognostic tools; include CFT, latex aglutination,
ID test
Epidemiology :
the saprophytic habitat of P. brasiliensis is not known; endemic mostly in
South America
Clinical features :
the primarily site of infection is the lung; disease may be benign, primary
pulmonary form or may disseminate to produce acute & chronic, progresive
disease, includes lymph nodes & skin
the primary benign form may ultimately results with some residual interstitial
fibrosis
progresive chronic pulmonary disease may involve all lobes of the lung;
produce extensive fibrosis
PARACOCCIDIOIDOMYCOSIS
Laboratory diagnosis :
Laboratory diagnosis :
Culture :
colony morphology : P. brasiliensis is a dimorphic fungus, grows slowly in the
mycelial form at room temperature; readily convert to the yeast phase when
grown at 370C on enriched media
Laboratory diagnosis :
Serology : CFT & ID test have been shown to be reliable; however cross reactions
may occur
Disease Agents
Pathogenic Opportunistic
CANDIDIASIS = Candidosis
acute / chronic fungal infections, involving, the mouth, vagina, skin nails,
bronchi / lung, alimentary tract, urinary tract, blood steam and less commonly,
the heart or menungen
Candida albicans :
is part of the normal flora of the skin, mucous membranes & GI tract along
with other Candida sp.
form elongated budding forms called pseudohyphae, which are often seen in
clinical material along with true hyphae, blastoconidia & yaest cells
CANDIDIASIS
is usually an extension of oral thrush & may include esophagitis & ultimately
the entire gastrintestinal tract
Laboratory diagnosis :
C. albicans be identified by :
* germ tube test -- yeast germination in serum at 370C
* culture on corn-meal-agar -- reveals chlamydospres
* culture on Eosin-methylen-blue-agar : reveals spider colony
* fermentation test of : glucose, lactose, maltose, sacharose
CRIPTOCOCCOSIS
include subacute or chronic fungal infections involving the lungs, meninges, or less
commonly the skin, bones & other tissues
Clinical feature :
Laboratory diagnosis :
ASPERGILLOSIS
is a ubiquitous filmentous fungus whose airborne spores are contantly in the air
is recognized both in tissue & in culture by its characteristic septate hyphae with
dichotomous branching, produced conidial heads with numerous conidia
ASPERGILLOSIS
it may begin as sinisitis or lungs; it disseminate to any part of the body, most
frequently brain
is an allergic disease, in which the organism colonies the mucous plugs form
in the lung, but does not invade lung tissue
caused by the genera Rhizopus, Mucor & Absidia; non-septate fungi; phylum
Zygomycota; grow repidly & predilection for invading blood vessels & the
brain
presents with facial swelling & blood tinged exudate in the turbinate bones &
eyes; lethargy & fixated pupil